Health care in America is again expected to be a deeply divisive issue in the 2020 U.S. presidential election, with Democrats pressing for more government involvement through the concept of 'Medicare for All,' and Republicans warning of increased taxes and looming socialism.

Health care advocates believe that growing public support for protecting and expanding health care programs will help Democrats in 2020, just as the party's focus on this issue helped it win control of the House of Representatives in the 2018 election.

Health care is a winning issue for Democrats. So, I think any way that they focus on health care and solutions is going to be beneficial to them, said Anne Shoup, with the advocacy group Protect Our Care.

Republicans, meanwhile, have been on the defensive of late, unable to agree on a conservative health care alternative to both bring down costs and ensure access to those in need.

Congressional Republicans and President Donald Trump failed in their effort to repeal and replace the Obama administration's signature health care program, but over time have reduced its coverage benefits.

Everyone wants to have health care for the sick. No one's trying to deny the sick health care. I think that's an important thing to clarify. What's important is how we achieve that, said Meridian Paulton, a conservative health policy analyst with The Heritage Foundation.

'Medicare for All'

The rising cost of health care continues to be a major concern in the U.S., where a typical family with no serious afflictions can spend over $8,000 a year, or 11 percent of their income on health insurance and basic medical care, according to the Kaiser Family Foundation that studies national health issues.

The crowded field of Democratic presidential candidates all endorse health care as a right, and favor a range of plans to achieve or work toward universal health care coverage and bring down costs.

The most expansive proposal is Vermont Sen. Bernie Sanders Medicare For All plan, a government takeover of the $2.5 trillion private health care industry that Sanders first proposed during his failed 2016 presidential election bid.

'The goal of a rational health care system is not to make insurance companies billions in profits,' Sanders, an independent seeking the Democratic presidential nomination, said at a recent rally in Iowa. 'So, we say to the health insurance industry, 'Yes, we will pass a Medicare for All single-payer program.'

Other Democratic candidates who support this single-payer approach that would ban private insurance plans include California Sen. Kamala Harris and Massachusetts Sen. Elizabeth Warren.

More moderate Democratic hopefuls such as Minnesota Sen. Amy Klobuchar and former Vice President Joe Biden, who reportedly is close to launching his campaign for president, endorse more incremental and pragmatic measures to expand health care that might stand a better chance of passing in a divided Congress.

The dilemma Democrats face in the 2020 campaign is whether to nominate a progressive candidate advocating for a complete health care overhaul which could alienate moderates in the general election or support a more moderate candidate who may not generate enthusiasm among the liberal base calling for transformational change.

Socialism

Trump, who is seeking a second term, has criticized Democratic health care proposals as socialism that will stifle individual choice and private enterprise competition.

'Democrat lawmakers are now embracing socialism. They want to replace individual rights with total government domination,' the president contends.

During the 2016 campaign, Trump repeatedly promised not to cut social assistance programs. But in this years budget, he has proposed reducing millions of dollars in funding for both Medicare health insurance for seniors, and Medicaid that provides medical assistance to the poor and disabled.

Democratic options

A recent public opinion poll by the Kaiser Family Foundation showed that 56 percent of Americans favor Medicare For All, and even broader support for incremental improvements to the current system in place.

However, public approval for expanding health care drops significantly when confronted with the possibility of doubling taxes to pay for it, and the economic disruption of eliminating the private insurance industry.

They have to believe that what they'd be getting, what would be substituting for what they have now, would be at least as good or attractive to them. And that the increase in the spending on the public side, that would be worth it to them, said Linda Blumberg, an economist with the Health Policy Center at the Urban Institute, a Washington think tank..

An incremental alternative that is gaining wider support among the American public, Blumberg says, is a government public option coverage plan to compete against private insurance companies.

Shifting support

The Affordable Care Act of 2010 increased access to health insurance by expanding Medicaid and providing insurance subsidies to working class families, while keeping in place the private sector health care and insurance industries.

The ACA, also known as Obamacare, was criticized for not containing the rising cost of health care, driven in part by a lack of competition in some markets, and by the role of for-profit insurance companies that charge excessive administrative fees.

Tea Party groups, limited government activists opposed to what they viewed as an increasing government takeover of the private health care industry, organized widespread Obamacare protests that helped the Republican Party win control of Congress in 2011 and to elect Trump in 2016.

However, Republican efforts in the last two years to repeal Obamacare failed, in large part because opponents did not have a clear alternative, and because the public favored keeping many elements of the ACA, particularly the prohibition against denying anyone health insurance because of pre-existing conditions such as a long-standing illness or pregnancy.